You can smoke it but you can’t study it: Cannabis researchers get creative
When customers speak, Medically Correct CEO Rick Scarpello listens.
“Quiq just came around from consumers saying, 'I want it to be more like smoking,'” Scarpello said of the fast-acting cannabis brand of topicals and edibles that launched last year. “People said, 'Look, I want to take this, I want to feel it right away.'”
While 37 states have approved medical marijuana to treat dozens of health conditions, the companies putting products in the hands of consumers rely not on lab-run clinical trials but on customer feedback to assess whether smoking or ingesting certain products eases pain or makes people feel energized or sleepy.
“We’re very limited in what we can and can't do,” Scarpello said. “The first few years of our business, the only legal way to test products would be to make a product, put it on the market and then go buy it.”
Colorado's Marijuana Enforcement Division now allows infused-products manufacturers like Medically Correct to bring home a limited number of products for development and quality control.
Scarpello is a believer --- he believes cannabis heals and his company helps sick people. But he is also quick to acknowledge the industry needs more scientific research behind it.
“I can’t say, ‘Hey, this will take away your pain in your arm.’ Honestly, I'd be a snake oil salesman. There's no clinical studies or double-blind trials to show that,” Scarpello said.
Federal law continues to block the clinical research needed to support or debunk the general efficacy of cannabis as a treatment for certain illnesses, much less the benefits of specific products.
“We have people saying, ‘Hey, take this strain if you need to sleep.’ Well, each strain has a different concentration of THC, but it's also got all these other compounds. There are over 100 cannabinoids and then we have bioactive lipids called terpenes,” said Dr. Kent Vrana, director of the state certified medical marijuana research center at Penn State's College of Medicine. “No one has studied to say that a strain is good for a disease.”
The U.S. Drug Enforcement Agency classifies cannabis with high levels of psychoactive THC as a Schedule I drug, meaning it's deemed to have high potential for abuse and no approved medical use. To study the plant, researchers must obtain a Schedule I license and purchase products from a lab approved by the National Institute on Drug Abuse, or NIDA.
A gulf, therefore, stands between what products the federal government approves for research and what consumers can buy down the street.
As a growing number of Americans consume cannabis each year for therapeutic reasons, understanding long-term and short-term benefits --- and risks --- becomes increasingly urgent.
“This is the first time we're talking about a drug that is very common, that is legalized for recreational use and legalized for medicinal use,” said Yasmin Hurd, director of the Addiction Institute at Mount Sinai. “It's very different for people from alcohol because we don't prescribe alcohol.”
“There has to be a better way of conducting clinical research so that researchers’ hands aren't tied so tightly that they can’t conduct the research. But of course, research that is monitored, where the results must be published whether or not the results are negative or positive,” Hurd added.
In place of clinical trials, some researchers have developed creative observational studies.
Cinnamon Bidwell, an assistant professor of cognitive science at the University of Colorado Boulder, was studying drug abuse when cannabis became legalized for recreational sales. She wanted to help fill in the gaps between policy and empirical scientific information.
“As an adult in my state, I can legally go to a dispensary and purchase a vast array of products for personal or medical use, but as a scientist in my state, I can't bring those state market products into my academic research lab to either independently test or study for their effects,” Bidwell said. “This leads to big gaps in terms of how people use cannabis and purchase cannabis on the legal market, versus what we can study and test.”
Because they couldn’t bring dispensary cannabis into the lab, researchers CUChange --- the University of Colorado Boulder’s Center for Health, Neuroscience, Genes, and Environment --- began bringing the lab to the cannabis.
Using cargo vans outfitted with equipment to draw and store blood on the go, researchers drive to participants’ homes to collect data before and after cannabis use.
Funded by $16 million in grants from NIDA, the National Health Institute and the state of Colorado among others, CUChange is one of few institutions able to answer questions on the benefits and risks of treating conditions like cancer, anxiety and migraines with cannabis, as well as effects on the use of other drugs like opioids and alcohol.
The lab still isn’t allowed to touch any of the products used by the 700 test subjects who have so far participated in various studies. Instead, it compiles a rigorous survey based on photos of products and packaging.
In addition to observational studies, medical professionals publish case studies from hospital patients.
As a medical student at the Philadelphia College of Osteopathic Medicine, Dr. Joshua Levy published a case study on a disease detected in a patient with heavy cannabis use and no other known risk factors.
Experienced as intense heartburn, Barrett's esophagus occurs when stomach acid erodes the tube's sensitive lining. Among other factors, it's a disease typically seen in overweight older white men with a family history of the disease.
Levy was therefore surprised to diagnose a case in a 41-year-old Black man with no apparent risk factors aside from the fact that he was a chronic cannabis user. Still Levy found no other research tying the disease to cannabis use.
Since publishing the paper, Levy has found a handful of other cannabis-smoking patients with Barrett’s esophagus, but there isn’t enough rigorous research to draw as strong of a link between cannabis use and the disease as there is with obesity or a history of acid reflux.
“They smoke marijuana, but we can't necessarily just blame the marijuana,” Levy said.
These unknown risk factors make doctors like Levy wary of recommending cannabis to patients, despite its popularity.
Dr. David Gorelick, editor-in-chief for the Journal of Cannabis Research, agrees.
“The public, just like medical professionals, should be very cautious when you have unknowns,” Gorelick said. “There are some published suggested guidelines for how physicians should deal with cannabis or cannabinoid medications and one of the principles which I agree with is why use a substance where we know less about the risks and benefits if we have FDA approved medications for which we have much better knowledge?”
Whether or not health professionals recommend medical marijuana, people are using it. As this past May, the Marijuana Policy Project estimates 5.4 million Americans were registered as medical marijuana patients with countless others self-medicating.
And while some want to see cannabis rescheduled or exceptions given to researchers, others say bureaucratic streamlining is needed to allow scientific knowledge to keep pace with the widespread use of cannabis.
“The fact that a single chemical entity can exist in three different regulatory spaces, depending on where you are, or how it was obtained, doesn't make any sense to me,” said Dr. Ryan Vandrey, a professor of psychiatry and behavioral sciences at Johns Hopkins Medicine.
“To have so many differences in opinion about the legality and access to and safety of cannabis and cannabinoids not only makes it difficult for research, but it causes confusion to the general public,” added Vandrey, who has conducted several clinical trials on cannabis dating back to 2003. He has used products sourced from NIDA, as well as studies designed around the absence of cannabis to understand withdrawal symptoms.
“Ultimately, we need to better understand the behavioral pharmacology of cannabis and cannabinoids broadly, we need to understand the impact of chemical variation, of route of administration, of formulation of dose,” Vandrey said. “Beyond that, all of the health claims need to be evaluated and need to be evaluated carefully.”
In the meantime, consumers continue to find what works for them through trial and error.
“We can educate consumers to shop for different chemical profiles in cannabis and also to trust their own instincts,” said Emily Fata, founder of the consulting firm Diagon Ventures. While Fata wants to see clinically proven products on the market, she also encourages customers to trust their nose.
“You obviously know when you smell the cannabis strain and you don't like it or when you do like it, so I do think that that's still the best way to shop,” Fata said.